Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans (AA). Repeated emergency room (ER) visits and rehospitalizations for symptom relief contribute to the $33.2 billion direct and indirect annual costs of HF. Common reasons for HF rehospitalization include delays in symptom recognition, medication and dietary noncompliance, and lack of knowledge and skills for competent self management. Evidence suggests that serious deficiencies in quality exist for patients undergoing transition across HF care settings, placing them at risk from fragmented care. Fragmented care can result in conflicting recommendations regarding HF self management, confusing medication regimens with high potential for error and duplication, inadequate follow-up, and inadequate patient and caregiver preparation to coordinate care among all healthcare settings. Transitional care delivered by nurses has been demonstrated to improve HF outcomes. Patient navigators have improved cancer care and community health workers have improved cardiovascular risk management, particularly among high risk minority populations; however, the patient navigator and community health worker models have not been applied to HF care. Limited evidence suggests that telemonitoring may be an effective strategy for improving outcomes, particularly in high risk HF patients. To address the gaps in HF care, we propose to refine and test an evidence-based HF care model that incorporates the best evidence, including telehealth, to improve HF care transition for AAs. This innovative HF care transition intervention (HFCTI) will be delivered by a nurse-community heath navigator team to AAs with HF and their caregivers. Components of the HFCTI include medication and symptom self management support, telemonitoring, and a personal HF care record. The HFCTI will be refined through patient focus groups and inpatient and outpatient clinician stakeholder assessments. Using a randomized controlled design, we will test the effect of the HFCTI on proximal (HF care transition, HF knowledge, HF self management) and distal outcomes (rehospitalization, ER visits, functional status, and HF-related quality of life) at 30, 90, 180 days after discharge from index hospitalization. This innovative, patient-centered, interdisciplinary model for HF care, with focus on enhancing self management and use of telehealth, has significant potential to improve self management and outcomes among AAs with HF, a population at disproportionately high risk. PUBLIC HEALTH RELEVANCE: Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans (AA). In this study, we propose to test an innovative, patient-centered, interdisciplinary model for HF care, with focus on enhancing self management and use of telehealth, which has significant potential to improve self management and outcomes among AAs with HF, a population at disproportionately high risk. [unreadable] [unreadable] [unreadable] [unreadable] [unreadable] [unreadable] [unreadable]